Public health concerns for food contamination in Ghana: A scoping review

Nutrition is sturdily and rapidly becoming the foremost determinant of health in today’s Sars-Cov-2 and climate change ravaged world. While safe food sustains life, contamination obliterates its values and could result in death and short to long term morbidity. The purpose of this scoping review is to explore food contamination in Ghana, between 2001–2022. Using Arksey and O’Malley’s procedure, a systematic literature search from PubMed, JSTOR, ScienceDirect, ProQuest, Scopus, Emeralds Insight, Google Scholar, and Google was carried out. Following the inclusion criteria, 40 published and grey literature were covered in this review. The review revealed the following: Studies on food contamination involving Greater Accra, Ashanti, Central, and Eastern Regions alone account for over 50% of the total number of such studies conducted in Ghana; regulators failed in enforcing regulations, monitoring and supervision; managers failed to provide adequate infrastructure and facilities. The most common food safety risks of public health concern are: i) micro-organisms (E. coli/faecal coliforms, Staphylococcus aureus, Salmonella spp, Bacillus cereus, and Viral hepatitis); ii) drugs (Amoxicillin, Chlortetracycline, Ciprofloxacin, Danofloxacin, and Doxycycline) and; iii) chemicals (Chlorpyrifos). Salad, vegetables, sliced mango, meat pie, and snail khebab are of high public health risks. The following deductions were made from the review: Highly contaminated food results in death, short to long term morbidity, economic loss, and threatens to displace Ghana’s efforts at achieving the Sustainable Development Goals (SDG) 2. Thus, Government must resource key regulatory bodies to enhance their operational capacity, regulators must foster collaboration in monitoring and supervision of food vendors, and managers of food service outlets must provide adequate facilities to engender food safety culture.


Introduction
Poverty, climate change, conflict, rapid population growth, illiteracy, negative socio-cultural factors, anthropogenic elements individually and collectively threaten the sanctity of foods consumed globally [1,2]. There is a strong correlation between food safety, nutrition and food

Rationale
Several studies reported incidence of food contamination, microbial examination of foods, and food poisoning in Ghana. Yet, the problem persists with increasing prevalence and threat to public health and safety. Therefore, there is need to explore existing evidence, highlight the areas of public health relevance and make recommendations for consideration.

Objective
The objective of this scoping review is to synthesis existing evidence on the phenomenon of food contamination in Ghana, with the view to contributing to knowledge on the subject.

Methods
We relied on published and grey literature to examine the prevalence and factors affecting food contamination in Ghana. Leveraging on Arksey and O'Malley's [22] procedure, we synthesized and analysed wide spectrum of useful published and grey literature from 2001 to 2022. The procedure includes: i) exploration and crafting of review objectives; ii) exploring vital literature; iii) sorting of relevant literature; iv) data mining; v) summary of data and synthesis of results, and vi) consultation [23]. Therefore, we stated four research questions: i) What is the prevalence and regional distribution of food contamination in Ghana? ii) What are the food-safety-related public health risks of ready-to-eat foods in Ghana? iii) Which foods are of high public health risk in Ghana, and What are the microbial qualities of ready-to-eat foods in Ghana? iv) What are the preventive measures against food contamination in Ghana?

Search strategy applied
Consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) strategy, we searched for useful published and grey literature for this review [24,25] (see Fig 1). The data search went through two levels. At level one, we applied words like "food" OR "contamination" OR "risk" OR "Ghana", which is intended to gauge the volume of data available on the subject. The results from the initial search included: PubMed (235), JSTOR (1,466), ScienceDirect (59,120), ProQuest (44,177), Scopus (59,120), Emeralds Insight (227), Google scholar (91,200), Google search (3,650,000). With additional words (see Table 1) added, a second level search was conducted and returned the following: PubMed (86), JSTOR (94), Scien-ceDirect (245), ProQuest (211), Scopus (112), Emeralds Insight (82), Google scholar (127), Google search (405). In all, 1,362 articles were located. The search exercise spanned April 21 st , 2022, to June 19 th , 2022. In keeping with the inclusion norms, 40 published articles were included in this review (see Table 1). All four authors, "EWA", "CES", "SD", and "NNB" individually extracted data from published articles that agreed with the inclusion norms for this scoping review. Meanwhile, "SD" and "EWA" fixed inconsistencies that emerged during data extraction. We categorized the phenomenon of food contamination in Ghana into five main themes, i.e.; i) prevalence and regional distribution, ii) causes, iii) microbial and other test results, iv) high risk foods, and v) prevention (see Table 2).

Discussion
The purpose of this scoping review is to explore food contamination in Ghana, between 2001-2022.

Prevalence and regional distribution of studies on food contamination in Ghana
There are more studies on food contamination conducted in the Ashanti, Central, Eastern, and Greater Accra Regions the rest of the regions in Ghana. The concentration of studies around these four regions could possibly be attributable to the high incidence of food contamination recorded. Given that Greater Accra and Ashanti Regions are the two biggest cities in Ghana, and are more densely populated, residents are also likely to patronise more of foodvendor services. Thus, the more outlets that prepare and provide food services to many consumers, the likelihood of recording high contamination if safety of the food is not paramount. Meanwhile, this pattern of prevalence is consistent with Omara et al. [64], where incidence of food contamination was found to be prevalent in some particular regions. The reason for this pattern may be because of the cosmopolitan nature of these regions [19,65]. Thus, it is essential that food safety is placed high in such regions and their cities to prevent health implications associated with poor compliance to food safety practices.

Food safety-related risks of public health concern in Ghana
Regulatory bodies tasked to ensure food safety in Ghana have, to a large extent, failed to enforce the regulations, carry out monitoring and supervision, and collaborate with each other in the discharge of their duties. This omission could be because they lack adequate logistics and personnel [66]. Again, managers/supervisors of food service outlets failed to provide adequate infrastructure and facilities, training, monitoring and supervision to their employees, as also observed by previous studies [66][67][68][69]. Moreover, food handlers are implicated for poor personal, food-safety and hygiene practices, cooking in unclean environment, poor sanitation, inadequate knowledge and skills, poor time and temperature controls, insufficient formal education and training, and medical screening [15,18,66,70], which could increase food contamination and cause food-borne illness to consumers. Therefore, consumers need to take food safety practices into their own hands by observing proper personal/food hygiene and safety practices [67].

Microbial quality of ready-eat-food with high public health risks
The high prevalence of contaminated foods reported in this review is a cause for worry. Most of the contaminants reported can pose serious public health and safety risk to the population [71]. Consumption of foods infected with micro-organisms like E. coli/faecal coliforms, Staphylococcus Aureus, cholera, and typhoid can result in short-to-long-term absence from work and school, hospitalization, or even death. Other contaminants like Clostridium Perfringens, Viral hepatitis, and Chlorpyrifos can impact an entire family or community in a very significant way [72,73]. This raises public health risk and safety implications of the high incidence of contaminated food.
We also identified and drew attention to some ready-to-eat foods with high levels of contaminants raising public health concerns. Some of these foods include salad, vegetables, sliced mango, meat pie, and snail khebab. These foods are of public health concern because these are popular ready-to-eat foods patronised widely by children, women, men, rich, poor, students, farmers, mechanics, etc.; this coheres with Akparibo et al. [74] who reported similar findings. Unfortunately, weak enforcement, monitoring and supervision on the part of regulators and managers, and inadequate knowledge, poor personal and environmental hygiene, austere economic conditions in Ghana now, and irresponsibility on the part of food vendors and consumers make these foods a clear and present public health threat to the population [6]. Therefore, school and working hours lost to hospitalisation and recuperation could further increase the vulnerabilities of the public [18,75].

Preventive measures against food contamination
It is important that food safety regulations are enforced, public education, training/capacity building, monitoring and supervision, surveillance/test for microbial and other elements are increased. Moreover, collaboration, and punishing offenders should be important for reducing the level of food contamination in ready-to-eat food in the country [16,17,66]. Similarly, education and training of food handlers, ensuring adequate supervision, providing workplace policies and establishing food-safety culture, provision of adequate facilities, surveillance/testing for microbial agents in food, medical screening, and motivation are critical measures to promote food safety [16,17]. Therefore, effective protection from the public health risks associated with contaminated foods can be attained through collaborative effort [76]. That is, the regulators and managers, especially, must commit to their mandate and be resolved to protecting consumers from food-related public health and safety risks [77,78].

Limitations
Though this review is first to comprehensively explore food contamination, prevalence and preventive measures, it also has some limitations. First, the review was wholly based on published and grey literature, hence may contain biases contained in those findings and conclusions. Second, we restricted the review to only articles published in English, that could affect the outcome of this review. Regardless of these confounding elements, a sample of 40 articles included in this review is sufficient to attain reliability and dependability of the conclusions reached. Moreover, one of the authors is an authority in Food Science, another, an authority in Environmental and Occupational Health and Safety, and another teaches Food Nutrition.

Conclusions and recommendations
We observed that to stem food safety-related public health risks in Ghana, the key regulatory bodies (FDA, EHS, MLGDR, GTA, VSD, and CPA), must scale-up: i) enforcement, ii) public education, iii) training/capacity building, iv) monitoring and supervision, v) surveillance/ microbial quality test, vi) collaboration, and vii) punishment of food safety offenders. Contaminated food is a public health risks that could result in death, short to long term morbidity, loss of funds, and threatens to displace Ghana's efforts at achieving the SDG (Specifically, SDG 2to eliminate hunger, attain food security, enhance nutrition and stimulate sustainable agriculture). The regulatory bodies must recommit to their mandate to address the status quo.
Though a lot of studies exist on food safety in Ghana, none gave a clear and comprehensive account of the prevalence and regional distribution of studies on food contamination. Moreover, the few reviews that exist failed to account for common food safety-related risks of public health concerns. Therefore, this review makes a significant contribution to knowledge on the subject. To attain a national food-control and safety system and guarantee public health and safety, we articulate the following recommendations: 1) government must resource the regulatory bodies to enhance their operational capacity, 2) regulatory bodies should collaborate in carrying out monitoring and supervision of food vendors, 3) managers of restaurants and other food service outlets must provide adequate facilities to engender food safety culture, 4) further, research on ready-to-eat foods posing the highest public health and safety risk and the populations most at risk of food contamination in Ghana.